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Tuesday, 29 January 2013

In US foreign relations with hostile states, President Obama declared in his inauguration speech this week, "engagement can more durably lift suspicion and fear." With his reelection behind him--in which he garnered more Cuban-American votes in Florida than any Democrat in history--and his legacy in front of him, here are steps the president should take to engage the Castro government and forge a sensible, sane, and productive US policy toward Cuba.

(1) Remove Cuba from the State Department list of nations that support terrorism. Among The Nation’s list of twenty ways the president should exercise his executive power is this long-overdue action. Cuba’s designation as a supporter of terrorism is an enduring injustice. Yes, Cuba has some criminal fugitives living on the island. But it is hard to accuse Cuba of harboring terrorists while Luis Posada Carriles, a prolific lifelong terrorist, is living freely in Florida. Moreover, Cuba’s current efforts to host and mediate a cease-fire and permanent peace accord between the FARC and the government of Colombia is hard evidence that it is playing a constructive role in seeking to end conflicts that breed terrorism in the region.

(2) While we are on the subject, Obama should order the arrest of Luis Posada Carriles and hold him under the Patriot Act until his extradition to Venezuela, from which he is a fugitive for the terrorist crime of blowing up a civilian airliner in October 1976, can be arranged. When the Bush administration let Posada set up residence in Miami in 2005, Venezuela sent a formal extradition request. If Obama is serious about fighting terrorism, he should finally grant that request.

(3) With Cuba off the terrorism list, Obama should end the economic and commercial sanctions that have accompanied its designation as a terrorist nation. The Department of the Treasury would thus cease to fine international banks for doing business with Cuba, which has undermined Cuba’s slow evolution toward a more capitalist-oriented economic system.

(4) And to support economic changes currently underway in Cuba, Obama should expand the general licensing for travel to Cuba of businessmen, scientists, citizens and others associated with industries like agriculture, travel, construction, oil, automobiles, healthcare and more. While the travel ban itself cannot be lifted without a majority vote in Congress, the president can create categories of general licensing that will allow far more Americans to freely travel to Cuba. Such a decree would instruct the Office of Foreign Assets Control to stop playing the role of travel dictator and simply provide all necessary licenses to travel agencies and educational interest groups involved in promoting travel to Cuba. Now, ironically, Cuban citizens are more free to travel here than US citizens are to travel there, since the Castro government lifted more than fifty years of restrictions on the ability of its citizens to travel freely abroad, earlier this month. If Obama is to be true to his overall commitment to advance civil rights, he can begin with the basic civil right of allowing US citizens to travel freely to Cuba.

(5) The president should also reconfigure the so-called “Cuban Democracy and Contingency Planning Program” mandated by the Helms-Burton Act and run out of USAID, from the failed “regime change” orientation to a set of transparent, non-interventionist “people-to-people” programs. Incoming Secretary of State John Kerry, who knows quite a bit about USAID's misconduct in Cuba from his tenure as Chair of the Senate Foreign Relations Committee, should immediately move to review and revamp the goals and operations of these misguided and counterproductive regime change efforts.

(6) To engage Cuba with normal diplomacy, Obama should order a bilateral dialogue on all areas of mutual interest: environmental cooperation, counternarcotics operations, counterterrorism, medical support for Haiti and more. On the agenda should be the case of contractor Alan Gross, who was sent to Cuba by the USAID Democracy Program on a quasi-covert mission to set up independent satellite network communications systems, and then abandoned to his predictable fate of being caught and tossed in jail. It’s time to let him return home to his family.

(7) Finally, Obama should commute the sentences of the so-called “Cuban Five”: Fernando González, Antonio Guerrero, Gerardo Hernández, Ramón Labañino, and René González (who is now on parole). These intelligence operatives were actually counterterrorism agents focused on anti-Castro exile groups that, frankly, have posed a threat to Cuban citizens and national security interests alike. All of them have served more than twelve years in US prison. They have been punished enough and also deserve to return home to their families.

Thursday, 10 January 2013

In early 2007, I began studying medicine at the Latin American School of Medicine in Havana, Cuba. I entered the program not knowing much about the Cuban healthcare system, other than that it was universal and free. “Now that’s a system I want to learn from,” I thought to myself, “It’s a system we could all learn from.” Five years later, what have I learned?

There are many subtle and not so subtle differences between the Cuban and the U.S. health care systems which have allowed the Cubans to equal the U.S. with respect to their health statistics, but at a much lower cost and with better preventative and primary care. In this paper I analyze just one of the reasons for the differences between the two systems; Cuba produces more primary care practitioners per capita. How do they do it? Medical education in Cuba is free, all doctors interested in specializing must first serve two years working in primary care, and graduating doctors are not driven to specialize by salary incentives. This socialist approach towards medicine and medical education assures the human resources necessary to provide universal and preventative healthcare to all.

People marvel at how Cuba has “accomplished so much with so little.” And they marvel with good reason. According to the World Health Organization, Cuba spent only $503 per capita on healthcare in 2009, the U.S. spent almost 15 times that sum. In fact we in the US spent $421 per person just on the administration of the private healthcare insurance system, almost enough to fund the Cuban system. Despite dramatically lower costs, Cuba has some of the best health statistics and health indicators of any country around the world.

Although people like to compare and contrast the health statistics of the U.S. and Cuba, I think this a bit preposterous. Cuba, a small island in the Caribbean, is being compared to one of the largest countries in the Americas with a very different history. So in the table below, I have shown some health statistics on Cuba and the U.S. as well as the Dominican Republic and Haiti. The Dominican Republic and Haiti are Cuba’s Caribbean neighbors; similar in size, history and geographic location.

*Statistical information provided by the World Health Statistics 2011 Report by the World Health Organization.

From this table, we can see that Cuba’s health indicators are more like those of the “first world” in the U.S. than its neighbors in the “third world.” The life expectancy of the U.S. and Cuba is almost identical. Cuba supersedes the U.S. in the categories highlighted. So we continue to ask, “How do they do it?” Could it have something to do with their philosophy that people need doctors? Hence, their solution is to offer a free medical education to develop young, quality doctors dedicated to serving those in need.

Per capita Cuba graduates roughly three times the number of doctors as the U.S. In 2005 Cuba had 70,594 doctors. Before the revolution in 1959, there were only an estimated 6,000 doctors; somewhere around half left the country after 1959. This means they must have graduated an average of 1,469 Cuban doctors per year, not including the some 5,000 international students who graduate each year from Cuban medical schools. When we later compare these numbers to the U.S. we see that Cuba graduates 3 times the number of doctors per capita, and the U.S. must import graduating doctors from other countries just to fill the primary care residency positions.

Critics of the “Obama Plan” say that there will not be enough doctors in the U.S. to take care of all the patients if everyone has healthcare coverage. Obama encouraged the Association of American Medical Colleges to increase the number of graduating doctors by 30% in 2010. Ever since 1980, U.S. Medical schools have graduated 16,000 doctors a year. Meanwhile, the population of the U.S. has grown 50 million during the same period. A 30% increase would have meant we should have graduated 20,800 medical students in 2010, but we only graduated 16,838 according to the Kaiser Family Foundation. The number of residency programs at teaching hospitals in the U.S. has been frozen since 1997, funded by Medicare.

There were 29,890 residency slots filled in 2009,positions not filled by American graduates are filled by International Medical Graduates. This means we can estimate more than 1/3 of students in U.S. residency programs are International Medical Graduates (IMGs), students from another country or a U.S. citizen, like me, who studied in another country.

In the current scheme of things, International Medical Graduates are continuously brought in to the U.S. to meet the needs of the growing patient population. Unfortunately nothing bridges the gap, because there just are not enough residency positions and/or funding for teaching hospitals to produce enough doctors to satisfy the entire U.S. population. Taking International Medical Graduates to meet the needs of the U.S. population only adds to the “brain drain” of developing countries around the world. So as we produce fewer doctors, introduce more doctors from other countries; U.S. doctors work harder for less to meet the needs in the U.S. and a lot of the world remains catastrophically underserved.

Cuba leads the world with the lowest patient to doctor ratio, 155:1, while the U.S. trails way behind at 396:1. With a surplus of Cuban doctors, Cuba is able to help ailing nations around the world. They have medical missions in over 75 different countries lead by nearly 40,000 health professionals, almost half of them are doctors. The United States by contrast imports doctors from poorer countries, further contributing to the brain drain of professionals from poorer countries to rich ones.

In Cuba education is free. Room and board, books and amenities are included. Doctors are not burdened by student loans and live comfortably though not extravagantly. Harvard Medical School states in their admissions statement that an “un-married first year medical student” will spend approximately $73,000 for the 2011-2012 academic year. This includes tuition, room and board, books, etc. Now times that by four and you have a whopping $292,000 to shell out to become a Harvard doctor. With interest rates, loan deferments and default charges, you might end up like Michelle Bisutti. She graduated medical school in 2003 with a $250,000 debt, in which by 2010 had increased to $555,000. This may be an extreme case, but the Association of American Medical Colleges projected in their 2007 report that in 2033, students on a 10-year repayment program will only see half of their after-taxes salaries, the rest going to loan repayment.

The cost of medical education in the U.S. causes more and more medical school graduates to turn to higher paying specialties and subspecialties rather than primary care or family medicine. Dr. Thomas Bodenheimer writing for the New England Journal of Medicine, stated that “between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent,” based on data from the National Resident Matching Program. In the U.S. specialists predominate at a ratio of 2:1 (the reverse of other Western countries) while half of all outpatient visits are made by primary care physicians. This deficit of primary care physicians decreases people’s access to primary care and preventative medicine, causing increases in health disparities and healthcare costs. This is because preventative medicine benefits the patient as well as reduces the number of Emergency Department visits and hospital stays. If there are no primary care physicians to provide preventative care to the population, we see the population suffer as costs continue to rise.

* Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates. From the American Academy of Family Physicians, based on data from the National Resident Matching Program.

According to a survey in 2008 by the American Academy of Family Physicians, family medicine graduates with less than 7 years of experience earn, on average, a yearly salary of $145,000. The difference in earnings between primary care physicians and specialists differed by only 30 percent in 1980, and dramatically rose up to 300 percent for some narrowly defined specialists by 2009. In the graph below, we show the dramatic difference between median compensation for selected specialties compared to that of primary care.

*Median Compensation for Selected Medical Specialties.

Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005.

When working in the U.S., almost every primary care physician I talk to has the same complaint, “Too many patients, and too little time.” They are forced to see 20 to 30 patients a day just to meet pay-incentives and “keep their doors open.” General/Family Practice physicians spend an average of 16.1 minutes with each patient per visit. Meanwhile, 18%, or roughly 48.2 million of the U.S. population under the age of 64 is without healthcare insurance. They have no access to most GP’s or family practice physicians.

We need to follow our Cuban role model, we need to be held socially accountable and produce more primary care physicians. This can be accomplished by providing an education at full scholarship to those interested in primary care, or by increasing the number of medical students going into primary care by closing the compensation gap between primary care and the higher paid specialties. These measures would ensure the population better access to quality primary care and preventative medicine. It would bring down the cost of healthcare while allowing primary care physicians to practice under less stressful conditions leading to quality affordable healthcare for all.